Abstract

Background: The aim of this study was to investigate the clinical anesthesia, intraoperative circulatory fluctuation and postoperative incisional pain of patients with end stage renal disease treated with peritoneal dialysis catheterization applied of ultrasound- guided transabdominal fascia block.

Methods: 40 patients diagnosed with end-stage renal disease who selected peritoneal dialysis catheterization were randomly divided into General Anesthesia (GA) group and Transversus Abdominis Plane Block (TAPB) group with different interventions.

Results: The mean arterial blood pressure and heart rate in GA group were significantly lower than those in TAPB group, the lowest after 10 min of induction (P<0.01), the VAS score at 24 h postoperatively in the TAPB group was significantly lower than that in the GA group (t=-3.637, P=0.001).

Conclusion: In conclusion, ultrasound-guided transabdominal fascia block is convenient for peritoneal dialysis catheterization, with good anesthesia effect, and does small disturbance to the respiratory cycle of patients.

Keywords

Peritoneal dialysis, Catheterization, End-stage renal disease.

Introduction

End-stage renal disease has the high incidence of one hundred
thousandth in China. The current treatment includes blood
purification (hemodialysis, peritoneal dialysis) and kidney
transplantation. Due to the severe shortage of donor and many
side effects of hemodialysis, peritoneal dialysis catheterization
becomes an important method of blood purification for patients
with end-stage renal disease. But traumatic operation of
peritoneal dialysis catheter surgery requires clinical anesthesia
by anesthesiologist. In current, there are three main clinical
ways of anesthesia: general anesthesia, spinal anesthesia and
local anaesthesia. Because patients with end-stage renal disease
are complicated by multiple diseases and organ dysfunction.
Both of the anesthesia ways have a greater risk and
complications for them. The aim of this study was to
investigate the clinical anesthesia, intraoperative circulatory
fluctuation and postoperative incisional pain of patients with
end stage renal disease treated with peritoneal dialysis
catheterization applied of ultrasound-guided transabdominal
fascia block.

Materials and Methods

General information

The participants were 40 patients. The inclusion criteria were
patients diagnosed with end-stage renal disease selecting
peritoneal dialysis catheterization. Exclusion criteria: local
anesthetic allergy history, long-term use of non-steroidal or
opioid analgesics. The participants were randomly divided into
General Anesthesia (GA) group and Transversus Abdominis
Plane Block (TAPB) group by randomized controlled trials. All
participants were numbered from 1-20, and then divided to 2
groups according to random number.

Monitoring and drug selection

After entering into the operating room, all patients were
monitored by ECG, noninvasive blood pressure, and oxygen
saturation by finger. The patients in GA group were also in
anesthesia depth monitoring. Before the start of anesthesia,
they were given 0.5 μg/kg dexmedetomidine hydrochloride for
sedation.

Anesthesia

The drug choice for TAPB group was 0.4% ropivacaine.
Operation: Ultrasound probe was placed in the Petit triangle side of the abdominal wall to make the imaging of obliquus
externus abdominis, obliquus internus abdominis and
abdominal transverse muscle the most obvious. After
distinguishing the transabdominal fascia between obliquus
internus abdominis and transverse abdominis, the needle came
into the plane of transabdominal fascia. Then the use of
ultrasound in-plane technology was applied to make the
puncture needle along parallel to the direction of the long axis
of the ultrasound probe. Ultrasound shows the needle goes
from shallow to deep. When the needle into the transversus
abdominis plane, no blood back to the suction, then inject 25
ml of 0.4 mg/kg. The induction regimen for GA group was 1
μg/kg etomidate, 0.4 μg/kg sufentanil, and 0.2 μg/kg
cisatracurium. The laryngeal mask was set after anesthesia
induction. Anesthesia maintenance program was sevoflurane
1-1.5 MAC for both two groups, to keep anesthesia between
the depths of 40-60.

Observational index

1: Record the start time of anesthesia, the start time for the
operation, anesthesia effect; 2: Observe and record average
arterial pressure, heart rate of the patients in the two groups
immediately before anesthesia and every 10 min after the start
of the anesthesia; 3: Observe and record the adverse reactions
of patients in the two groups, including severe circulatory
fluctuations (mean arterial blood pressure decreased more than
20% of immediately before anesthesia), respiratory depression,
arrhythmia, nausea, vomiting and abdominal muscle tension
were recorded with and without anesthesia. 4: Pain scores were
evaluated at 2, 4, 8, 12, and 24 h after operation by Visual
Analogue Scale (VAS) (0 was painless and 10 was severe
pain); 5, Side effect was recorded within 24 h after operation:
Respiratory depression, hypotension, dizziness, nausea,
vomiting and itching.

Results

There were no statistically significant differences in sex, age,
height and weight between the two groups (P>0.05) (Table 1).

Group

Age (Y)

Weight (Kg)

Stature (Cm)

Gender (M/F)

TAPB

58 ± 12

53 ± 10

161 ± 9

11/9

GA

60 ± 11

56 ± 9

163 ± 7

10/10

Table 1: Comparison of general information (n=20, ͞x ± s).

There were 11 cases of grade I anesthesia and 9 cases of grade
II in TAPB group, while 18 cases of grade I anesthesia and 2
cases were of grade II in GA group. The anesthesia effect of
GA group was better than that of TAPB group. The difference
between the two groups was statistically significant. Sedation
analgesics used in the TAPB group were applied to relieve
peritoneal exploration or discomfort during peritoneal
exploration or placing peritoneal dialysis catheter tube.

The change of cycle before and after anesthesia was listed in Table 2. The heart rate and mean arterial blood pressure in
TAPB group had no significant change. However, the mean
arterial blood pressure and heart rate in GA group were
significantly lower than those in TAPB group. The lowest one
was after 10 min of induction (P<0.01). In the GA group, 11
patients were treated with dopamine, significantly higher than
those in the TAPB group.

Indicators

Group

Before

10 min

20 min

30 min

40 min

50 min

60 min

Mean arterial pressure (Mmhg)

TAPB

105.6 ± 12.6

109.3 ± 8.5

107.3 ± 11.6

101.2 ± 7.6

103.6 ± 10.2

106.4 ± 11.9

103.7 ± 10.5

GA

108.2 ± 9.3

90.3 ± 13.3

92.6 ± 115.6

95.5 ± 17.3

99.1 ± 17.6

102.8 ± 10.6

101.9 ± 11.9

Heart rate

TPAB

83.6 ± 8.6

88.2 ± 9.6

86.3 ± 10.5

85.8 ± 8.7

84.3 ± 9.7

85.2 ± 11.2

84.3 ± 10.3

GA

82.5 ± 9.6

75.6 ± 13.5

79.3 ± 10.8

84.3 ± 9.7

85.2 ± 8.5

84.9 ± 10.2

84.6 ± 9.8

Table 2: Comparison of the change of mean arterial pressure and heart rate of the patients in the two groups (n=20, ͞x ± s).

As indicated in Table 3, the VAS score at 24 h postoperatively
in the TAPB group was significantly lower than that in the GA
group (t=-3.637, p=0.001). In the TPAB group, there was no
lower limb motor nerve block after surgery, while the patients
in the GA group were restricted in their ambulation after
general anesthesia. No respiratory depression, hypotension,
dizziness, nausea, vomiting and itching occurred in the two
groups within 24 h after operation.

Discussion

Most patients with end-stage renal disease are associated with
renal hypertension and coagulation dysfunction. Preoperative
hemodialysis need to be done within the control environment.
Although general anesthesia has the advantages of rapid onset,
high patient comfort, severe circulatory fluctuations and
tracheal tube discomfort increased accident rate of
perioperative cardiovascular and cerebrovascular. There are
T7-L1 lateral dorsal cutaneous branch through the Petit triangle
of lateral side, which is the anatomical basis of fascial blocking
technique [1,2]. Ultrasound-guided transabdominal fascial
block can accurately inject drugs into the nerve fascia, greatly
improve the success rate of block, work quickly and greatly
reduce the incidence of complications. Because the peripheral
nerve is small, postoperative analgesia can also be maintained
for a long time.

Recently, many studies reported the application of ultrasoundguided
transabdominal fascia in the clinical abdominal surgery
[3-5]. The method has been applied to intraoperative or
postoperative analgesia in colorectal surgery, obstetrics and
gynecology, hernia surgery, and achieved satisfactory results.
Fu et al. [6] compared the transabdominal fascial block with
intramedullary block, also suggesting the former superior to
the latter.

In this study, transabdominal fascia block meet the surgical
analgesia in the incision, at the same time has little effect on
the patient's breathing and circulation. Compared with the
general anesthesia group, they can postoperatively eat food
faster, get out of bed earlier, and have a lower VAS score. In
the surgery for the exploration of rectovaginal pouch or uterine
rectum pouch, it is need to take a small amount of sedative
analgesic drugs to relieve discomfort, which is the lack.

Ultrasound-guided transabdominal fascia block is convenient
for peritoneal dialysis catheterization, with good anesthesia
effect, and does small disturbance to the respiratory cycle of
patients. Also it can reduce the hospital stay and hospitalization
costs, which is a superior anesthetic option for patients with
end-stage renal disease patients for peritoneal dialysis
catherization.